By Z. Daro. Silver Lake College.
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Nevdakh 1 Introduction Companies such as Cenegenics emerged to advertise antiag- ing therapy as a combination of diet, exercise, supplements, Although the masterminds of humanity (Michelangelo, and hormones . However, what follows is the “state of the Goethe, Picasso, and Newton) all lived past 80 years of age art” in antiaging medicine in 2012, based on scientiﬁc and and led productive lives without the help of modern medi- clinical research. We have gained more 2 Conventional Approach years in life expectancy in the recent century than the dawn of mankind, likely due to improvements in medical technol- 2. With or without the help of medicine, the maximum average life span of a human being The only established method of aging retardation is caloric has been projected to be between 85 and 95 years. This theories have been proposed to explain the biological mecha- method also seems to delay the onset of age-related diseases nism of aging, but among these the “telomere hypothesis” and maintain youthful physiologic functions . When a cer- a 30 % caloric restriction has shown an average core tempera- tain length of telomere is reached, the cell evokes the ture decrease of 0. Hence, the body temperature reduc- lenged by “scientiﬁc” discoveries – aging became a disease. Caloric restriction was able to moderate the age-dependent loss in autophagy regulation I. With the decline of testosterone, symp- cellular organelles as natural by-products of cellular func- toms such as decrease in muscle mass and strength, cog- tion . These reactive species cause oxidative damage to nitive decline, lowered bone density, and an increase in target molecules of mitochondria and lysosomes located in adipose tissue in the abdominal region arise [21 ]. Antioxidants of this correlation, interest in using sex hormones, espe- assist other enzymes such as superoxide dismutase in the cially testosterone, has developed in recent years for antiag- body to prevent reactive species from damaging cellular ing therapy . In the human body, iron is an important source of on the effects of testosterone, most likely due to differ- the potent antioxidant bilirubin Ix . The primary source ences in experimental design, overall health of subjects, and of cellular iron is heme iron . Free radical oxygen inactivates ble-blind, randomized, placebo control of 237 healthy men bilirubin and deprives the cell of its natural antioxidant between 60 and 80 were conducted over a 15 month period [16 ]. These subjects had testosterone levels lower than the correct intermediaries from forming during heme bio- 13. The control group and the variable group synthesis, resulting in an accumulation of oxygen-reactive supplemented with testosterone had no signiﬁcant differ- species that cause cellular damage . However, 15 clini- ence in muscle strength, bone density, or cognitive abilities cal trials including antioxidants such as tocopherol, beta- , but the variable group did experience an increase in carotene, vitamin C, vitamin E, retinol, and folic acid have lean body mass and decrease in body fat mass as well as been conducted and none has shown a statistically signiﬁ- body fat percentage . Metabolic syndromes Lycium barbarum is a common ingredient in oriental medi- such as coronary artery diseases and strokes increased more cine and is known for nourishing the liver and improving in the testosterone group than the control group most likely eyesight . Also, the polysaccharides may have antiaging, anti- changed signiﬁcantly in either group . More research and studies must be done to conclu- ing from metabolism and nonenzymatic glycosylation of sively state the physiological impact of supplemental testos- D-galactose. Thus, it seems to P450c17 has two enzymatic activities, 17--hydroxylase and be difﬁcult to reproduce the therapeutic results achieved 17, 20-lyase. The amount of increase in thesis without a change in cortisol levels with age [27 ]. Most sity, anti-diabetic, anti-atherosclerosis and anti-osteoporosis importantly, these long-lived mutant rodents display vigor effect . However, a more recently conducted 2-year and cognitive abilities in ages when these animals normally double-blind experiment in 2006 by Nair et al. Comparison of 24 Human growth hormone levels are high early in life, corre- healthy adults with 24 patients with pituitary disease, all over sponding to somatic growth, but decrease soon after physical 60 years old, indicated that the latter have signiﬁcantly and sexual maturation . FoxO transcriptional factors have normally healthy elderly individuals with human growth gained attention in current research regarding antiaging due 1232 A. A defect in the klotho gene in mice lead The mammalian target of rapamycin is an evolutionarily to symptoms akin to human aging: shortened life span, infer- conserved protein kinase pathway that controls cell prolif- tility, growth arrest, hypoactivity, and skin atrophy [52 ]. Since it is evolution- klotho gene encodes for a type of transmembrane protein arily conserved, its effects can be equally potent in a yeast only expressed in the distal convoluted tubules of the kidney cell or a human cell .
Surg Endosc 9(10):1146 Heloury Y buy cheap reminyl 8mg line, Plattner V cheap 4mg reminyl with amex, Mirallie E order reminyl 4mg without prescription, Gerard P, Lejus C (1996) Laparoscopic Nissen fundopli- cation with simultaneous percutaneous endoscopic gastrostomy in children. Br J Surg 81(2):161–163 Katkhouda N, Steichen F, Ravitch M, Welter R, Mouiel J (1989) Integrated anastomotic resection in esogastric surgery. Lyon Chir 85:190–191 Selected Further Reading 99 Katkhouda N, Khalil M, Grant S, Manhas S, Velmahos G, Umbach T, Kaiser A (2002) Andre Toupet: surgeon technician par excellence. Gut 38(4):487–491 Mouiel J, Katkhouda N, Gugenheim J, Fabian P, Crafa F, Iovine L (1992) Endolaparoscopic Vagotomy. Ann Surg 248(6):1081–1091 Nissen R (1956) Eine Einfache operation zur beeinfussung der Refuxesophagitis. Ann Thorac Surg 61(4):1062–1065 Ozmen V, Musleumanoglu M, Igci A, Bugra D (1995) Laparoscopic treatment of duodenal ulcer by bilateral truncal vagotomy and endoscopic balloon dilatation. Arch Surg 130(3):289–293 Rebecchi F, Giaccone C, Farinella E, Campaci R, Morino M (2008) Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundopli- cation for achalasia: long-term results. Ann Surg 248(6):1023–1030 Rossetti M, Hall K (1977) Fundoplication in the treatment of gastroesophageal refux in hiatal hernia. World J Surg 1:439–444 Sakuramachi S, Kimura T, Harada Y (1994) Experimental study of laparoscopic selective proximal vagotomy using a carbon dioxide laser. Surgery 143(2):278–285 Gastric Surgery 6 Pyloroplasty A laparoscopic Heineke–Mikulicz pyloroplasty is performed in the same way as an open surgery. The most commonly encountered diffculty is recognition of the pyloric muscle through the scope. For this reason it is advisable to note some of the landmarks that can be sought out, such as the pyloric vein of Mayo running on the muscle’s surface and the change in diam- eter between the distal end of the stomach, the pyloric area, and the postpyloric region. It is usually possible to identify the pylorus using these anatomical features; however, in case of diffculty, the procedure can begin and once underway, a laparoscope can be inserted into the duodenum from the gastric side of the pyloroplasty, permitting recog- nition of the pyloric muscle by the change in caliber. In such cases, one can remove one trocar, insert a fnger into the opening after partially defating the abdomen and locate the pylorus by palpation (Fig. When the pyloroplasty has been created longitudinally, it is possible to suture it transversely exactly as in open surgery using interrupted stitches of 3–0 Prolene (the 4–0 suture used in open surgery is a little too thin and the risk of breaking the suture is greater). The 3–0 suture will give adequate strength for intracorporeal or extracorporal knot-tying; both are possible. The author advises buttressing the pyloroplasty with a small omental patch as an extra safety measure (Fig. Vagotomy with An antrectomy can be combined with a bilateral truncal vagotomy in the treatment Antrectomy or of gastric outlet obstruction. The laparoscope should be able to conveniently access both the hiatus, in the case of a bilateral truncal vagotomy, and the greater curvature of the stomach, especially if the stomach is dis- tended as in gastric outlet obstruction. Before starting the operation it is important to insert a nasogastric tube to decompress the stomach, thus avoiding any injury to the stomach upon insertion of the Veress needle. A umbilicus; B surgeon’s right hand (scis- sors); C surgeon’s left hand (grasper), D assistant’s grasper; E subxiphoid port. It is advisable to start outside the gastroepiploic arcade and divide the arcade at the end of the dissection (Fig. A key maneuver to facilitate the operation is to change the position of the camera at each step of the procedure to obtain a more direct view of the structures involved with each phase of dissection. During the frst step, while working on the gastrocolic ligament, the camera is placed at the umbilicus and the two hands of the surgeon are positioned on each side of the camera. As the dissection proceeds towards the antrum and the inferior aspect of the duodenum, the camera is moved to the port at the surgeon’s right hand, and the two other ports are triangulated with the camera. These concepts are extremely impor- tant: (a) fexibility and mobility of the camera position, and (b) triangulation (Fig. Before the actual dissection is begun, it is important to check on the various land- marks: the curvatures of the stomach, the gastrocolic ligament and the gastroepiploic arcade, the inferior aspect of the antrum, the duodenum and the pyloric muscle, the lesser sac, and the right gastric artery. The limit of the antrum and proposed site of the gastrojejunostomy is marked using electrocautery. An asterisk marks the beginning of the dissection (divi- sion of the gastroepiploic arcade) Fig. Few vessels are encoun- tered, but one should stay very close to the gastroepiploic arcade to avoid injury of the transverse colon. Dissection proceeds slowly to the inferior aspect of the duodenum at the area where the proposed transection will be performed. At this point the right gastroepiploic artery is divided between clips, rather than applying electrocautery or using the harmonic shears alone. Division of the right gastroepiploic artery precedes the posterior dissection of the duodenum. Using a right-angled dissector, exactly as it is used for dissection of the esophagus, a retroduodenal passage is created starting at the inferior aspect of the duodenum. Dissection then proceeds to the superior aspect of the duodenum and the right gastric artery is ligated between clips and divided. At this point a right-angled 10 mm dissector is introduced into the subxyphoid port to complete the dissection behind the duodenum, as the subxyphoid port is immediately in line with this dissection (Fig. This permits the introduction of a 60 mm linear cutter through the same subxyphoid port in the same direction, and transection of the duodenum is carried out. Blue loads are typically used, but green loads are preferred if the duodenum is thickened. Two important points have to be considered: The duodenum is very fragile and usually infamed, especially in gastric outlet obstruction. Several applications of the cutter without fring will only destroy the various layers and increase the risk of a duodenal stump leak. Here, it is advisable to use one fring of a 60-mm cutter because the duodenum is not an easy organ to handle with cutters, and it is diffcult to cross staple lines on the duodenum. Once the duodenum is transected, the stomach can be pulled upward and the lesser cur- vature is skeletonized. The posterior attachments of the stomach to the pancreas are divided, thus allowing full mobilization of the stomach. Two anastomotic techniques exist for creation of the gastrojejunostomy: intra- abdominal gastrojejunostomy and laparoscopically-assisted gastrojejunostomy. After gastric transection with the linear cutters, the specimen may be removed through a 3 cm muscle splitting incision using one of the trocar sites (Fig.
Steroids are z Except for syphilis order 4mg reminyl otc, each one of them in its primary form only indicated in the presence of infammatory lesions such infects the baby purchase reminyl 8 mg with mastercard. Late sequelae include deafness reminyl 8 mg, psychomotor retarda- tion, seizures and cerebral calcifcation. Diagnosis Demonstration of a positive IgM in cord or neonate’s blood in frst 2 weeks of life clinches the diagnosis. Antiviral agents, ganciclovir and and petechiae in an infant with microcephaly, hepatosplenomegaly and patent ductus arteriosus. Clinical Features Congenital defects include cardiovascular malforma- tions, microcephaly, cataracts and microphthalmia. Abortion may be the outcome of the infrequent fetal Late sequelae include deafness, mental retardation, thy- infection occurring early in pregnancy. If diagnosed in frst trimester, neous vesicles and ocular lesions (keratoconjunc- medical termination of pregnancy is advisable. Diagnosis z Notched central incisors 407 z Interstitial keratitis and saber shins. Herpes simplex virus can be diagnosed by the following methods: Diagnosis Tzanck smear made from skin lesions. Existence of vitamin A defciency in the mother boosts the risk of vertical transmission 3–4 times. Usually, the infant is asymptomatic at birth and may rem- During passage through the birth canal, risk is certainly ain so during the frst 6 months. On the other hand, actually infected infants and pale, owing to the presence of inflammatory cells may turn out to be seronegative at 15 months. Good nursing care and good nutrition constitute the main- z Head may be microcephalic or hydrocephalic. Ideally, in Late manifestations (usually after 2 years of age) include: prosperous families, breastfeeding should be withheld. Cotrimoxazole as a prophylax- Fetal manifestations include limb hypoplexia, paresis, is against Pneumocystis carinii (new name Pneumocystis microcephaly, hydrocephaly, microopthlamia, duodenal jiroveci) is in order. Mode of Infection Infection is by direct physical contact, or air-borne contact Treatment with droplets of respiratory secretions after the primary In case of severe maternal infection antiviral acyclovir infection resolves. Triad of cataract, congenital heart disease and deafness (sensorineural) usually occurs in: A. The triad of “seizures, chorioretinitis and calcifcation in brain” is seen in each of the following, except: A. Review 2 A 6-day-old neonate presents with pyrexia, irritability, progressive lethargy, seizures, bulging fontanel and high-pitched cry. Since there is evidence of signifcant embryopathy, it seems intrauterine infection occurred in the frst trimester, in all probability frst 4 weeks. Of course, further manifestations may be in the form of late sequelae such as deafness and mental retardation. Essentially, Risk Factors these are not present at the time of admission to the hospi- tal. All infections in newborns delivered in the hospital need to T ese infections may afict not only the patients, but be considered acquired except those caused by organisms also staf members, volunteers, visitors and attendants, reaching the baby from the mother at or before the time etc. Eye infections In order to monitor the prevalence of nosocomial may be due to Gonococcus and Chlamydia. According to conservative estimates, their Infections appearing after frst few days of life are predominantly caused by enterobacteria, Pseudomonas incidence ranges from 2. Stay of the neonate in the hospital for more than a week is likely to lead to Staphylococcal skin infection of both Table 24. It often occurs in epidemics nosocomial infections associated with single strain of Staphylococcus aureus. According to one report of infection with Skin swabs from suspected carriers should be rubbed Mycobacterium tuberculosis, babies born in obstetric unit over the chosen site. Corynebacterium diphtheriae, Clostridium tetani, Hemo- Textile, linen, cotton and dressing may harbor patho- phillus infuenzae, virus (A, B, non-A, non-B), rubella, gens capable of causing hospital infection. Small por- infuenza, respiratory syncytial, Candida, Mucor and tion of each of them, if available, may be dipped into Pneumocystis carinii. Exposure of blood agar plates in pairs at various sites Mode of Transmission in the operation theater to fnd risk of aerial contami- Contact spread: Contact with a number of contami- nation of wounds. Infants with infections that can spread by airborne Airborne spread: Tis involves an organism that has a route must be separated from other infants, preferably true airborne phase in its route of dissemination which out of nursery area. Vector-borne spread: Vector-borne transmissions, both Surveillance program, using multiple techniques to external and internal, can cause nosocomial infections. Internal vector-borne trans- Critical evaluation of new procedures and techniques mission includes harborage (Yersinia pestis) and biologic into the nursery, e. Gastroenteritis; organisms responsible are Shigella, Each section should have facilities for intensive care Salmonella, rotavirus,Yersinia, Vibrio cholerae, Campylo- and resuscitation so that undue movement of equip- bacter and Clostridium difcile. It should be the policy to retain the same cot Pathology during the whole hospital stay of the child. If possible, Major pathologic fndings in anaerobic infection consist of the cot should be washed with soap and water and abscess formation and widespread tissue destruction. A pottie with opened plastic bag should be Clinical Features provided with each cot. Anaerobic infection of the upper respiratory tract usu- Ward foor, toilet, wash basins, sinks, etc. It is better to have apical abscess, osteomyelitis of mandible or maxilla, foot-operated taps and two-way swing doors to pre- chronic sinusitis, otitis media, mastoiditis, peritonsillar vent frequent touching. Terapy chiefy consists of intensive antibiotic cover, Anaerobic infection of the lower respiratory tract may nutritional rehabilitation, and, if the need arises, plastic present as necrotizing pneumonia, putrid empyema surgery later. Manifestations of anaerobic septicemia include Anaerobic bacteria are agents that poorly tolerate oxygen. Birth after prolonged rupture of membranes, amnionitis Anaerobes may be categorized as per Box 24. Spore-forming: Clostridium tetani, Clostridium perfringens, Congenital or acquired disorders in which response Clostridium botulinum, Clostridium novyi, Clostridium septicum, to infection is impaired. Arachnia gangrene, infection close to mucosal surface, endo- bacterium, Propionibacterium.
Independent of the gender of the examining health-care clinician buy generic reminyl from india, it is strongly recommended that a female chaperone the health-care clinician during the entirety of the examination cheap reminyl. If a chaperone is declined then this should be documented contemporaneously buy reminyl uk, preferably with witnessing. The patient should be placed in the lithotomy position and the examining health-care clinician should use vulvoscopy (Figure 64. In addition, warming the room creates a more relaxed environment in which the patient will feel more comfortable. External Examination The first part of the examination involves inspection of the vulva and labia majora. Two gloved fingers are placed on either side of the clitoral shaft, and using an upward force in the cephalic direction, the prepuce is retracted to gain full exposure of the glans clitoris, corona, and right and left frenulum emanating at 5:00 and 7:00 from the posterior portion of the glans clitoris (Figure 64. The labia minora are inspected for labial resorption and for their ability to meet at the midline posterior fourchette (Figure 64. The maximal labial width is recorded to compare pre- and posthormone supplementation. Using gauze to maximally retract the labia minora, the labial–hymenal junction (Hart’s Line) is identified. The Q-tip cotton swab is placed at multiple locations on the vestibule, which is defined as the tissue medial to Hart’s line (Figure 64. A Q-tip cotton swab test is performed, gently applying pressure on the minor vestibular glands (Figure 64. The examining health-care clinician should use vulvoscopy with magnified vision and a focused light source. The patient should be placed in the lithotomy position and wear a sheet to cover her lower torso. Internal Examination For the speculum examination, a warm, lubricated speculum is used. Single-digit palpation is achieved by gently placing a finger into the vaginal opening and depressing the bulbocavernosus muscle. Two fingers are placed against the lateral walls of the levator and underlying obturator muscles, which are assessed for tenderness. Neurourological Testing Neurourological examination consists of sensory and reflex testing . The sensory neurological exam evaluates the integrity of the three branches of the pudendal nerve including the dorsal nerve of the clitoris (sensation from the glans clitoris and clitoral shaft), the perineal nerve (sensation from the perineum and labia), and the inferior rectal nerve (sensation from the perianal skin). Testing sites include the right and left sides of the clitoral area, labia majora, labia minora, and perianal areas. Sacral reflexes include the bulbocavernosus reflex and the anal wink reflex, and both sensory and motor arms of these reflexes are branches of the pudendal nerve. The afferent arm of the bulbocavernosus reflex is the dorsal nerve of the clitoris, and the efferent arm is the perineal nerve. The index and middle fingers are placed along the posterolateral aspect of either the right or left vaginal wall overlying the bulb of the clitoris, surrounded by the bulbocavernosus muscle. A gentle pinch of the glans clitoris with the opposite hand will elicit contraction of the bulbocavernosus muscle (Figure 64. The examination is repeated with the examining fingers facing the opposite vaginal wall. The afferent and efferent arms of the anal wink reflex both arise from the inferior rectal nerve. The anal wink reflex is performed using the wooden shaft end of the Q-tip and is assessed by touching the perianal skin, about 1 cm from the anus at the 3 o’clock and the 9 o’clock positions. Visible contraction of the anal sphincter will be noted after touching the skin . Objective sensory nerve testing may be performed with a biothesiometer (Figure 64. This quantitative sensory test measures vibratory perception thresholds (expressed in volts) and values are obtained in a nongenital reference site (pulp index finger) as well as in multiple genital sites such as the glans clitoris (dorsal nerve of the clitoris) and the right and left labia minora (the perineal nerve). Other quantitative sensory testing involves determination of hot and cold perception threshold values in these test sites (Figure 64. The health-care clinician may also perform a complete physical exam, such as examining for a thyroid goiter, to rule out other comorbid conditions that might be causing sexual dysfunction. A general physical exam is highly recommended in women with chronic illnesses and as part of good medical care, including a detailed breast exam and evaluation of blood pressure and heart rate. Laboratory Testing There is no consensus on recommended routine laboratory tests for the evaluation of women with desire, arousal, and orgasm sexual health concerns. Blood testing should be dictated by clinical suspicion, especially from the results of the history and physical examination. There are multiple concerns with the determination of serum hormone levels, especially testosterone [34–36]. The normal ranges of testosterone concentration values for women of different age groups without sexual dysfunction are not well defined. Testosterone levels reach a peak during the early follicular phase, with small but less significant variation across the rest of the cycle. Testosterone assays are not uniformly sensitive or reliable enough to accurately measure testosterone at the low serum concentrations typically found in women. Equilibrium dialysis is a highly sensitive assay for free testosterone; however, this method is not feasible for clinical practice. Androgens, including testosterone, not only are necessary for reproductive function and hormonal balance in women but also represent important precursors for the biosynthesis of estrogens. Historically, androgens were identified predominantly with male sexual function, contributing to a lack of recognition of the effects of androgens in women. We know that androgens have multiple biochemical effects in the body including but not limited to sexual desire, bone density, muscle mass and strength, mood, energy, and psychological well-being. However, sex steroid hormone actions are quite complex and involve critical enzymes and critical hormone receptors that also determine tissue exposure, tissue sensitivity, and tissue responsiveness. In our office, we have located a small subset of women who do not respond to typical doses of testosterone 1020 (1/10 the dose for men), and we hypothesize that they have a deficiency in the 5-alpha-reductase enzyme . Data from psychometrically validated questionnaires were assessed for parametric data analysis. After initial treatments with one testosterone pellet, the mean treated testosterone values increased to 141.
However cheap reminyl 4mg on-line, those patients who are especially both- touring effective reminyl 4 mg, including brachioplasty order reminyl 8 mg without a prescription, has been also increasing. Indeed, most other body contouring problems are far more favorably camouﬂaged by warm weather clothing than the 3 Preoperative Planning upper arm “batwing” deformities. Even though brachioplasty (also referred to as upper In addition to a systematic approach to presurgical exami- arm dermatolipectomy) typically provides reliable long- nation of these patients, a series of photos and an exam in term correction of these problem areas, the resulting scars front of a large mirror are vital in evaluating and instruct- are some of the greatest disincentives for patients contem- ing prospective patients in what to expect from their bra- plating the procedure. Preoperative photographs should though hidden when the arms are positioned by the side, include the standard anterior-posterior, oblique, and lat- they can draw attention in poses with the arms abducted. A dynamic exam in front outcome by both minimizing scar hypertrophy and expe- of a large mirror should help educate the patient and sur- diting scar maturation. These images should be printed and readily available dur- ing the surgical procedure for easy reference, as the anat- R. Hoy tissue of the posterior arm, and the areas of planned resec- 5 Reﬁning Approaches to Brachioplasty tion are tentatively marked. Typically, the incision place- ment will vary slightly as the ﬂap is tailored on the The ﬁrst aesthetic brachioplasty technique was published in operating table. Because Initial physical exam should concentrate on determina- patients had unacceptable cicatrical contractures, especially tion of asymmetries. An elliptical dermatolipectomy is in the axilla, subsequent authors sought to modify the proxi- always necessary and the distal apex in most cases can be mal extent of the scar. Previously described Z- or W-plasties limited to the distal upper arm, not crossing the elbow. The dorsal or following table illustrates various researchers’ technical con- inferior edge skin over the triceps muscle is typically much tributions and is modiﬁed from Pinto et al. Stretch marks which notoriously plague this inner Contemporary surgeons are increasingly adept at incor- arm region should be eliminated to the greatest extent pos- porating the brachioplasty as part of an upper-body rejuvena- sible. We begin marking by pulling in an inferior direction tion in the massive weight loss patient [12 – 14]. In fact, the on the lax soft tissues of the extended medial upper arm combination of brachioplasty with upper-back resection, and with the patient in the standing position. A lengthwise mark breast reconstruction, is now considered an upper-body lift is made while exerting this pull from just proximal to the [4, 15], which is analogous to the more common lower body elbow to the axilla. In a thorough analysis of their prospective registry of axillary skin is then pulled from the lateral edge of the pec- body contouring patients, Gusenoff and colleagues  toralis major in a posterior direction and brought as far found that patients who had experienced massive weight loss anteriorly as possible while allowing concealment within required longer, more extensive procedures and had more the axilla and then a right angle line continued in the midax- wound healing problems, but that the complications more illary line. Some patients present with complaints of xylocaine with epinephrine along the anterior longitudinal upper arm fullness, but may have good skin tone and rela- marking. Approximately 30 cc per arm is used to then inject tively little excess adiposity of the posterior upper arm. Incision is made under full These patients, especially younger patients with preserved epinephrine effect (Fig. Bovie dissection is used initially elasticity of the dermis, may respond better to upper arm until the muscular fascia is reached. This technique will not be supramuscularly, a plane which is surprisingly loose, and addressed in depth in this chapter, as it is not applicable as this maneuver easily separates the tissues to be eliminated a single technique for addressing more severe adiposity and from the underlying muscle fascia. This picture is often seen in states of obesity, encountered in this dissection unless the muscle fascia is or as one of the sequelae of signiﬁcant weight loss. Small vessels and cutaneous nerves patients, both fatty tissues and skin need to be resected, i. Those with a history of The excess “pannus” is fully mobilized before initiating morbid obesity invariably have the most extensive upper excision (Fig. This class of patients vertical direction and the skin from the anterior and posterior also may have involvement of the forearm and elbow margins are stapled together (Figs. The tension regions requiring a longer incision for aesthetic removal of and aesthetic tightening are judged by looking and feeling redundant tissues. For further detail, the appreciated, the staple is removed and the vertical incision is reader is directed to a helpful algorithmic approach to these lengthened and the edges are stapled together again. A line is drawn between the inter- ﬁnally and then Medipore tape placed along the entire length vening segments and they are excised with scalpel and Bovie. The Staples are removed and the edges are stapled approximated closed incision, with drain in place, is shown (Fig. The same tailor tacking is employed once again with the proximal remaining pannus 7 Peri- and Postoperative Care and redundant skin is excised. Meticulous hemo- The postoperative inﬂammatory response, edema, and stasis is important but easily accomplished because of the ecchymosis seen in brachioplasty can be modulated to a cer- epinephrine-induced vasoconstriction. Pain control requirements tend to be minimal and proximal forearm adiposity juxtaposed to the elbow is then include mild narcotics initially and nonsteroidal anti- performed (Fig. Gentle compressive forces are rine into that area 10 min before initiating liposuction to provided to prevent ﬂuid collection: an elasticized garment is avoid overdistention and maximize the ability to recognize worn for at least a month postoperatively and Medipore tap- the optimal contours in that area. The operative time has decreased by one Patients return to light work in 1 week but are advised to third or more by using this system. Just prior to ﬁnal sutures are placed at proximal and distal wound margins, a #10 8 Avoidance of Complications Jackson-Pratt drain is placed by taking a long 3 mm liposuc- tion cannula and introducing it through an axillary stab inci- Brachioplasty represents a challenge for many surgeons and sion. The cannula is then advanced subcutaneously to the has historically had a high complication rate. Wound dehiscence to the tube (to help keep it temporarily ﬁxed to the cannula) is or necrosis of the ﬂap edges may occur, and post-massive pulled attached to the cannula through from the distal edge of weight loss patients may be slow to heal due to previously the incision through to the axilla (Fig. Dermabond is applied which is comparable to those rates in panniculectomy or belt 438 R. The authors found that skin-excision ultrasound-assisted lipoaspiration is avoided at the medial weight correlated with seroma rate and that each additional elbow due to the nearby course of the ulnar nerve. As in other body contouring proce- dures, the risk for seroma can be decreased with limitation 9 Results/Cases of undermining and placement of drains. If the tissues are not contoured symmetrically, contour irregularities includ- The following example is a 48-year-old female who under- ing depressions or folding of excess remaining tissues could went bilateral brachioplasty. Contour irregularities, if they do occur, are often due terior, and lateral views are shown (Figs. The reported scar revision rate after brachio- 13, 14, 15, 16, 17, and 18 and the postoperative results shown plasty is 10 % in some series , and this is an area of noto- in Fig. Nerve injury, major wound very aesthetic appearance to the upper arm with resolution of complications, and lymphedema are potential complications, the excessive posterior curvature of the arm. Hoy 10 Futures and Controversies Some authors advocate staging the deﬁnitive brachioplasty with an initial session of liposuction. The liposuction is performed 3–5 months prior to the brachioplasty to reduce the excess subcutane- ous fat: this is argued to maintain the skin’s elastic recoil proper- ties and reduces the extent of dissection .
In addition to the assumptions just listed buy reminyl mastercard, it should be noted that in a repeated- measures experiment there is a presumption that correlations should exist among the repeated measures generic reminyl 4mg overnight delivery. That is buy reminyl from india, measurements at time 1 and 2 are likely correlated, as are measurements at time 1 and 3, 2 and 3, and so on. This is expected because the measurements are taken on the same individuals through time. This assumption, coupled with assumption 3 concerning equal variances, is referred to as sphericity. Most computer programs provide a formal test for the sphericity assumption along with alternative estimation methods if the sphericity assumption is violated. The Model The model for the fixed-effects additive single-factor repeated measures design is xij ¼ m þ bi þ tj þ eij (8. Consequently, the notation, data display, and hypothesis testing procedure are the same as for the randomized complete block design as presented earlier. In this study, 18 of the subjects completed a survey questionnaire assessing physical functioning at baseline, and after 1, 3, and 6 months. The goal of the experi- ment was to determine if subjects would report improvement over time even though the treatment they received would provide minimal improvement. We wish to know if there is a difference in the mean survey values among the four points in time. We assume that the assumptions for the fixed-effects, additive single-factor repeated measures design are met. F with 4 À 1 ¼ 3 numerator degrees of freedom and 71 À 3 À 17 ¼ 51 denominator degrees of freedom. We first enter the measurements in Column 1, the row (subject) codes in Column 2, the treatment (time period) codes in Column 3, and proceed as shown in Figure 8. The first test is used under an assumption of sphericity and matches the outputs in Figures 8. The next three tests are modifications if the assumption of sphericity is violated. Note that the assumption of sphericity was violated for these data, but that the decision rule did not change, since all of the p values were less than a ¼ :05. The analyses are easily expanded to include testing for differences among times for different treatment groups. As an example, a clinic may wish to test a placebo treatment against a new medication treatment. Researchers will randomly assign patients to one of the two treatment groups and will obtain measurements through time for each subject. Assumptions The assumptions of the two-factor repeated measures design are the same as the single-factor repeated measures design. However, it is not uncommon for there to be interactions among the treatments in this design, a potential violation of Assumption 5, above. For this reason, and at the level of the intended audience using this text, we will assume that interaction effects, when present, are mathematically handled using a statistical software package that provides correct calculations for this issue. The Model The model for the two-factor repeated measures design must represent the fact that there are two factors, A and B, and they have a potential interaction. These features, along with the block effect and error, must be accounted for in the model, which is given by xijk ¼ m þ rij þ ai þ bj þðabÞij þ eijk (8. These were a placebo treatment (treatment 1) and an aloe juice group (treatment 2). Cancer health was measured at baseline and at the end of 2, 4, and 6 weeks of treatment. The goal was to discern if there was any change in oral health condition over the course of the experiment and to see if there were any differences between the two treatment conditions. We assume that the assumptions for the two-factor repeated measures experiment are met. When H0 is true and the assumptions are met, each of the test statistics is distributed as F. If all assumptions are met for the within-subjects effects, we will have F with 4 À 1 ¼ 3 numerator degrees of freedom for the time factor, ð4 À 1Þð2 À 1Þ¼3 numerator degrees of freedom for the interaction factor, and ð4 À 1Þð25 À 2Þ¼69 denominator degrees of freedom for both tests; interpolation from Table G provides a critical F value of 2. Further, for the between-subjects factor, we will have ð2 À 1Þ¼1 numerator degrees of freedom and 25 À 2 ¼ 23 denominator degrees of freedom; Table G gives the critical F value to be 4. If we do not meet the assumptions, specifically of sphericity, then the computer program will alter the degrees of freedom and hence the critical value for comparisons. However, both the critical values for the interaction effect and the between-subjects factor are quite small and less than the necessary critical value, and we therefore fail to reject these two null hypotheses. We conclude that there is no statistical difference between treatments, but that subjects did have a change in oral condition through time regardless of the treatment they received. To summarize: since p <:001, we reject the null hypothesis concerning changes through time. Since p ¼ :931, we fail to reject the null hypothesis concerning the interaction of time and treatment. Since p ¼ :815, we fail to reject the null hypothesis concerning differences between treatments. It is evident that changes in oral condition did occur through time, but that the two treatments were very similar, as can be seen by the close proximity of the two curves. Further, it is evident that interaction between time and treatment occurred, as evidenced by the crossing of the plotted lines. The outcome variable was a neurological function variable measured on a scale of 0–12. Rat 60 Minutes 24 Hours 48 Hours 72 Hours 1 2 3 4 5 6 7 8 9 10 11 9 7 7 Source: Data provided courtesy of Ludmila Belayev, M. The following table shows the loads (in newtons) required to achieve different graft laxities (mm) for seven specimens (data not available for one specimen) using five different load weights. Graft laxity is the separation (in mm) of the femur and the tibia at the points of graft fixation. Lintner, “Multistranded Hamstring Tendon Graft Fixation with a Central Four-Quadrant or a Standard Tibial Interference Screw for Anterior Cruciate Ligament Reconstruction,” American Journal of Sports Medicine, 31 (2003), 338–344. The researchers examined dietary journals of the subjects over the course of 2 weeks and then computed the average daily selenium intake. The following table shows the average daily selenium intake values in mg=d for the 16 women in years 1, 2, and 3 of the study.
The MiniArc Pro system varies with its earlier two counterparts by incorporating a visual feedback system allowing repeatable cheapest reminyl, standardized control discount reminyl 8 mg overnight delivery. A feedback system has been employed that utilizes a stationary scale and an indicator that moves relative to the scale if the mesh is elongated or tensioned buy 4 mg reminyl visa. This marking system allows for the placement of the sling under the portion of the urethra being supported in a consistent manner. The edges of the center 4 cm of the mesh (advertised as the suburethral portion) are bonded together to potentially reduce irritation and the possibility of mesh erosion or extrusion. The anchors on the sling are designed to secure maximum pullout force while allowing a flexible secure placement. The tensioning sutures on either end of the mesh allow for a movable anchor with two-way adjustability. Preoperative considerations: Insertion of a minisling may be performed under many different types of anesthesia, including general, spinal or epidural, regional, and local. Patient positioning: The patient is positioned in the dorsal lithotomy position with legs in stirrups. The perineum and vagina are sterilely prepared and draped so as to exclude the anus. Lateral labia majora retraction stitches may be placed or a self-retaining retractor may be used to improve vaginal exposure. A weighted vaginal speculum is placed, and bladder drainage is accomplished with a Foley catheter. An Allis clamp may be placed distal to the incision, with care taken not to traumatize the urethral meatus, to facilitate visualization. Vaginal flap dissection: Dissection of lateral vaginal flaps proceeds in a standard fashion with attention to developing an appropriately robust and well-vascularized vaginal flap, while not jeopardizing the thickness of the periurethral tissue. This flap is carried laterally and anteriorly until the endopelvic fascia is encountered, but the retropubic space is not entered (Figure 75. Preparation of the Sling: The sling is prepared by inserting the tip of the delivery device or needle into the self-affixing end of the mesh apparatus, ensuring that the mesh is oriented on the outside of the delivery needle. The placement should be immediately posterior to the 1166 ischiopubic ramus; the needle can be “walked off” the posterior aspect of the bone, maintaining a close proximity to the posterior surface of the bone. The tip should be advanced until the midline marking on the mesh is situated under the middle of the urethra. The needle is removed from the mesh, attached to the other end of the mesh device, and inserted on the contralateral side in a similar manner, ensuring the mesh lies flat under the urethra, until the proper degree of desired tension is achieved. This arrangement allows for the mesh to be inserted further, if more tension is desired. The redocking procedure entails threading a 2–0 polypropylene suture through the tip of the mesh assembly and then through the tip of the delivery device, knotting one end. This end of the mesh is placed first, in the usual fashion, and then the delivery needle is removed, leaving the suture in place. If further tensioning is warranted, the free end of the suture is reinserted into the end of the delivery needle, and the needle is advanced along the suture, sliding into the tip of the mesh device. After appropriate dissection is completed, the fixed anchor is pushed into the tissue until it is slightly beyond the ischiopubic ramus. A metal tip of the trocar extends past the anchor allowing for an easier placement of the anchor into the obturator membrane. The adjustability of the sling is independent of its insertion and does not lock, which allows the loosening of the sling should it be found to have been set too tightly. Vaginal closure: The vaginal incision is closed in the same way as described previously in which the anterior sulcus is trimmed, and the vaginal incision is closed. Outcomes of the studies were objective and subjective and assessed at 12 and 24 months postoperatively. Randomized control trials included the use of MiniArc, Ajust, Ophira, and Solyx slings. These include bladder injury or perforation, bleeding, vaginal mesh extrusion, urinary tract mesh erosion, voiding dysfunction, and urinary retention. Viscous organ damage and major vascular injury still may occur but in theory should be much less common because the needle/trocar trajectory through the retropubic or obturator space is significantly more truncated by design of the minisling. If bladder perforation occurs and is discovered on cystoscopy, the sling should be immediately removed. The implanted sling should be in close apposition to the urethra with no laxity in the material. The surgeon should use a clamp or right angle to determine that there is no redundancy in the sling material. This could be secondary to improved design with alteration of the trajectory as well as improved surgeons’ understanding of the minisling procedure. Single-incision mini-slings versus standard midurethral slings in surgical management of female stress urinary incontinence: A meta-analysis of effectiveness and complications. Trends in surgical management of stress urinary incontinence among female Medicare beneficiaries. Single-incision mini-sling compared with tension-free vaginal tape for the treatment of stress urinary incontinence: A randomized controlled trial. A randomised trial of a retropubic tension-free vaginal tape versus a mini-sling for stress incontinence. Single incision mini-sling versus a transobturator sling: A comparative study on MiniArc and Monarc slings. A randomized, controlled trial comparing an innovative single incision sling with an established transobturator sling to treat female stress urinary incontinence. Short term outcomes with the Ajust system: A new single incision sling for the treatment of stress urinary incontinence. Urinary incontinence in women: Variation in prevalence estimates and risk factors. Transobturator vs single-incision suburethral mini-slings for treatment of female stress urinary incontinence: Early postoperative pain and 3-year follow-up. A 2-year observational study to determine the efficacy of a novel single 1169 incision sling procedure (Minitape) for female stress urinary incontinence. Preliminary findings with the Solyx single-incision sling system in female stress urinary incontinence.